Why Every Woman with a Medicare Advantage HMO Plan Needs to Call Their Insurance Company Before Seeing a Specialist

Sue had recently retired and was enjoying the freedom that came with having more time for herself and her family.

One morning after a swim, Sue noticed a suspicious dark spot on her shoulder that she had never noticed before. Her husband encouraged her to have it checked, so she made an appointment with her primary care provider (PCP) she chose when she recently signed up for a Medicare Advantage Health Maintenance Organization (HMO) Plan.

Upon examining the spot, her doctor referred her to a dermatology specialist. Sue assumed that because the referral came directly from her PCP, everything would be covered, in-network, by her Medicare Advantage HMO plan except for her usual copayment.

Sue subsequently visited the dermatologist, who removed the spot, confirmed it wasn’t cancer, and Sue drove home relieved.

A few weeks later, that relief was replaced by confusion when Sue received her Explanation of Benefits (EOB) from her insurance company. Turns out, her visit hadn’t been covered because the dermatologist was out-of-network with her Medicare Advantage HMO plan!

Sue’s Story Is Not Uncommon

Many Medicare Advantage HMO members assume that if their doctor refers them to a specialist, the provider must be covered by their insurance.

While primary care providers do their best to refer you to specialists, labs or facilities within your insurance network, provider participation can change throughout the year. In addition, your doctor’s office may not have access to the most up-to-date network information for your specific Medicare Advantage HMO plan.

Specialists’ offices often verify insurance before appointments, and many will notify patients if they discover they are out of network with their plan. But mistakes happen, and sometimes patients don’t learn there’s a problem until they view their EOB or a bill arrives.

Protect Yourself with One Simple Step

Before scheduling an appointment with any specialist, imaging center, or laboratory:

• Call your Medicare Advantage plan and confirm the provider is in-network with your specific plan.
• Even if your doctor’s office says the provider participates with your insurance, verify it yourself.
• If a specialist’s visit, a test or a procedure is scheduled for a couple of months from now or more, make a follow-up call to your insurance company a few days before your visit, just to confirm network status at that time.
• Write down the date, time, and name of the insurance representative you spoke with, along with what they confirmed.

What to Do If You Receive an Unexpected Bill

First, do not assume there’s nothing you can do!

Contact your Medicare Advantage plan as soon as possible to find out why the claim was denied and to obtain your appeal rights, along with the process your insurance company requires you to follow for an effective appeal.

In your appeal letter, explain that you were referred by your PCP, and you were never informed that the provider – whether it was a specialist, a lab or a facility – was out-of-network. Also include that the specialist’s office itself never contacted you before your appointment to inform you that they were out-of-network with your plan.

Just as importantly, include in your appeal letter that if you had known the entity that you were referred to was out-of-network in the first place, you would have obviously never chosen to see them.

While an appeal doesn’t guarantee payment, it’s often worth pursuing.

The Moral Here? It’s So Much Easier to Be Proactive Than Reactive

The best way to avoid an unpleasant surprise is to verify your specialist, a lab or a facility before your appointment. One quick phone call can save you hundreds of dollars, prevent unnecessary stress, save you from having to appeal, and give you confidence that you are receiving care that is covered.

When it comes to your Medicare Advantage HMO plan, a few minutes of preparation today can protect both your health and your finances tomorrow!

Questions for You:

Have you ever been in this situation before where you discovered you saw an out-of-network provider? How did you handle it? Did you appeal, and what was the outcome? On the other hand, if you are in the habit of calling your insurance company to verify network status before visiting a provider other than your PCP, can you give advice on how you have made this action an effective habit?